Does preoperative American Society of Anesthesiologists score relate to complications after total shoulder arthroplasty?

BACKGROUND

For hip and knee arthroplasties, an American Society of Anesthesiologists (ASA) score greater than 2 is associated with an increased risk of medical and surgical complications. No study, to our knowledge, has evaluated this relationship for total shoulder arthroplasty (TSA) or reverse total shoulder arthroplasty (reverse TSA).

QUESTIONS/PURPOSES

We aimed to assess the relationship between the ASA score and (1) surgical complications, (2) medical complications, and (3) hospitalization length after TSA, reverse TSA, and revision arthroplasty.

METHODS

We retrospectively analyzed all patients who had undergone TSAs, reverse TSAs, or revision arthroplasties by the senior author (EGM) from November 1999 through July 2011 who had at least 6 months' followup. Of the 485 procedures, 452 (93.2%) met the inclusion criteria. Data were collected on patient demographics, comorbidities, hospitalization length, and short-term (≤ 6 months) medical and surgical complications. Logistic regression analysis modeled the risk of having postoperative complications develop as a function of the ASA score.

RESULTS

Patients with an ASA score greater than 2 had a greater risk of having a surgical complication develop (p < 0.001; OR, 2.27; 95% CI, 1.36-3.70) and three times the risk of prosthesis failure (ie, component dislocation, component loosening, and hardware failure) (p < 0.001; OR, 3.23; 95% CI, 1.54-6.67). Higher ASA scores were associated with prolonged length of hospitalization (effect size 0.46, p < 0.001), but not medical complications.

CONCLUSIONS

ASA score is associated with surgical, but not medical, complications after TSA and reverse TSA. The ASA score could be used for risk assessment and preoperative counseling.

LEVEL OF EVIDENCE

Level III, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Complications of rotator cuff surgery-the role of post-operative imaging in patient care

When pain or disability occurs after rotator cuff surgery, post-operative imaging is frequently performed. Post-operative complications and expected post-operative imaging findings in the shoulder are presented, with a focus on MRI, MR arthrography (MRA) and CT arthrography. MR and CT techniques are available to reduce image degradation secondary to surgical distortions of native anatomy and implant-related artefacts and to define complications after rotator cuff surgery. A useful approach to image the shoulder after surgery is the standard radiography, followed by MRI/MRA for patients with low "metal presence" and CT for patients who have a higher metal presence. However, for the assessment of patients who have undergone surgery for rotator cuff injuries, imaging findings should always be correlated with the clinical presentation because post-operative imaging abnormalities do not necessarily correlate with symptoms.

Changes in collegiate starting pitchers' range of motion after single game and season

The relationship of changes in glenohumeral range of motion (ROM) in a pitcher's throwing shoulder to a single pitching episode is not well described, and the causes of such changes over a season are controversial. We hypothesized that in pitchers for a collegiate baseball team, external rotation (ER) would increase, internal rotation (IR) would decrease, total ROM would be maintained, and the glenohumeral IR deficit would worsen in starting pitchers' shoulders after single pitching episodes and after the season. Participants were 6 starting pitchers for all 25 home games from a Division III National Collegiate Athletic Association team during 1 regular spring season. One examiner measured glenohumeral ER, IR, and total ROM with the arm abducted 90° pregame before stretching or throwing and immediately postgame before shoulder icing. Bilateral measurements were obtained on supine pitchers via a long-arm goniometer and custom bubble inclinometer. Innings, pitch count, and types of pitches were recorded for possible associations with any glenohumeral motion changes. Paired t tests were used to compare dominant and nondominant glenohumeral differences in ROM (significance, P < 0.05). Compared with pregame values, single-start postgame glenohumeral ER significantly increased (7.9° ± 2.2°), single-start IR did not significantly change, and single-start total ROM significantly increased (7.4° ± 3.4°). Compared with preseason values, postseason glenohumeral ER significantly increased (10.2° ± 6.2°), IR significantly decreased (-17.8° ± 6.7°), and total ROM significantly decreased (-7.7° ± 5.2°). In the collegiate throwing shoulder, changes in ER and total ROM occurred after 1 episode of starting pitching, and changes in ER, IR, and total ROM occurred over the full season. There was no association between the ROM changes and innings pitched, pitch count, or types of pitches thrown. In conclusion, for collegiate pitchers, changes in glenohumeral ROM occur after single starts and over the season, suggesting that monitoring motion changes throughout the season may be beneficial.

Uncommon indications for reverse total shoulder arthroplasty

Total shoulder arthroplasty and shoulder hemiarthroplasty have been the traditional method for treating a variety of shoulder conditions, including arthritis, cuff tear arthropathy, and some fracture types. However, these procedures did not provide consistently good results for patients with torn rotator cuffs. The development of the reverse prosthesis by Grammont in the late 20th century revolutionized the treatment of the rotator-cuff-deficient shoulder with arthritis. The main indication for the reverse prosthesis remains the patient with cuff tear arthropathy who has pain and loss of motion. Because the reverse total shoulder arthroplasty produced such good results in these patients, the indications for the reverse prosthesis have expanded to include other shoulder conditions that have previously been difficult to treat successfully and predictably. This review discusses and critically reviews these newer indications for the reverse total shoulder arthroplasty.

Impingement is not impingement: the case for calling it "Rotator Cuff Disease"

Historically, many causes have been proposed for rotator cuff conditions. The most prevalent theory is that the rotator cuff tendons, especially the supraspinatus, make contact with the acromion and coracoacromial ligament, resulting in pain and eventual tearing of the tendon. However, more recent evidence suggests that this concept does not explain the changes in rotator cuff tendons with age. The role of acromioplasty and coracoacromial ligament release in the treatment of rotator cuff disease has become questioned. Evidence now suggests that tendinopathy associated with aging may be a predominant factor in the development of rotator cuff degeneration. We propose that the overwhelming evidence favors factors other than "impingement" as the major cause of rotator cuff disease and that a paradigm shift in the way the development of rotator cuff pathology is conceptualized allows for a more comprehensive approach to the care of the patient with rotator cuff disease.

The Latarjet coracoid process transfer procedure: alterations in the neurovascular structures

BACKGROUND

The Latarjet coracoid process transfer procedure is an established, reliable treatment for glenoid deficiency associated with recurrent anterior shoulder instability, but changes in neurovascular anatomy resulting from the procedure are a concern. The purpose of our cadaveric study was to identify changes in the neurovascular anatomy after a Latarjet procedure.

MATERIALS AND METHODS

We obtained 4 paired, fresh-frozen cadaveric forequarters (8 shoulders) from the Maryland State Anatomy Board. In each shoulder, we preoperatively measured the distances from the midanterior glenoid rim to the musculocutaneous nerve, axillary nerve, and axillary artery in 2 directions (lateral to medial and superior to inferior) and with the arm in 2 positions (0° abduction/neutral rotation; 30° abduction/30° external rotation), for a total of 12 measurements. We then created a standardized bony defect in the anterior-inferior glenoid, reconstructed it with the Latarjet procedure, and repeated the same measurements. Two examiners independently took each measurement twice. Inter-rater reliability was adequate, allowing pre-Latarjet measurements to be combined, averaged, and compared with combined and averaged post-Latarjet measurements by using paired Student t tests (significance, P ≤ .05).

RESULTS

We found (1) significant differences in the location of the musculocutaneous nerve in the superior-to-inferior direction for both arm positions, (2) notably lax and consistently overlapping musculocutaneous and axillary nerves, and (3) an unchanged axillary artery location.

CONCLUSIONS

The Latarjet procedure resulted in consistent and clinically significant alterations in the anatomic relationships of the musculocutaneous and axillary nerves, which may make them vulnerable to injury during revision surgery.

Proximal biceps tendon tear in an adolescent tennis player

The diagnosis of a torn biceps tendon in athletes who use overhead throwing or swinging motions can be difficult to make because there is no one physical examination finding that will confirm the diagnosis, and because magnetic resonance imaging, although sometimes helpful, does not image the length of the biceps tendon adequately. We report a case of an isolated partial biceps tendon tear in an adolescent female athlete who was diagnosed during arthroscopy after the tendon was pulled into the joint. The tendon was cut and a tenodesis was performed. Two years after the surgical procedure, the patient was without pain and returned to playing tennis at her previous level.

Postoperative death associated with a reverse prosthesis

The mortality rate after total shoulder arthroplasty, and specifically after reverse total shoulder arthroplasty, has not received much attention in the literature. Although complications of the reverse total shoulder arthroplasty are well known, fatalities secondary to complications related to the unique features of the reverse prosthesis have not, to our knowledge, been previously reported. We report the case of an elderly man who developed shoulder instability after the implantation of a reverse prosthesis followed by disassociation of the glenosphere from the baseplate. After a reoperation to revise and reassemble the components, he developed an infected shoulder and sepsis, and subsequently died from the complications of sepsis. This death represents a perioperative mortality rate of 0.5% in our series of 190 cases. The mortality rate after reverse total shoulder seems to be similar to that after standard total shoulder arthroplasty.

Malignant soft tissue tumors of the biceps muscle mistaken for proximal biceps tendon rupture

Tears of the proximal long head of the biceps tendon are among the most common tendon tears in the body. In most cases, the diagnosis is easily determined based on the history and physical examination. However, malignant soft tissue tumors can simulate proximal biceps tendon tears. Although tumors simulating tears of the distal biceps tendon at the elbow have been reported, to the authors' knowledge, no previous cases of tumors simulating or being mistaken for proximal biceps tendon tears have been reported.This article describes 2 cases of malignant sarcomas initially mistaken for tears of the long head of the biceps tendon. In the first case, a 62-year-old woman developed swelling in her arm after feeling a twinge in her shoulder. A magnetic resonance imaging scan was misread as a biceps tendon tear and not treated by the examining physician. In the second case, a mass appeared with little trauma in the brachium of a 70-year-old man. On physical examination, the mass was hard to palpation. In each case, biopsy revealed a soft tissue sarcoma. Both patients underwent wide excision with radiation and are currently disease free. These 2 cases emphasize the importance of obtaining a good history and of performing a thorough shoulder and arm examination in patients with deformities consistent with tears of the long head of the biceps tendon.

Glenohumeral range of motion in major league pitchers: changes over the playing season

Background:

Although overhead throwing athletes may develop unique glenohumeral range of motion characteristics, to our knowledge these characteristics have not been studied longitudinally in major league pitchers.

Hypothesis:

Major league pitchers (starters and relievers) experience an increase in glenohumeral external rotation and a decrease in internal rotation and total range of motion. Glenohumeral internal rotation deficit worsens over a regular playing season.

Study Design:

Retrospective cohort study.

Methods:

In 21 major league baseball pitchers (29 individual playing seasons), glenohumeral range of motion was measured in external and internal rotation for the throwing and nonthrowing shoulders before and at the conclusion of the regular season. The total range of motion (the sum of external rotation and internal rotation) and the glenohumeral internal rotation deficit were calculated (the difference between internal rotation of the nonthrowing shoulder minus that of the throwing shoulder), and data were compared between starting and relief pitchers.

Results:

The overall mean changes in external rotation (+1.5°), internal rotation (+2.7°), and total range of motion (+3.3°) were not statistically significant. However, starting pitchers showed statistically significant increases in internal rotation (+6.5°, P = 0.01) and total range of motion (+7.9°, P = 0.04), whereas relief pitchers had significant worsening of glenohumeral internal rotation deficit (+5.3°, P = 0.04).

Conclusions:

The characteristics of glenohumeral range of motion in major league pitchers did not differ significantly from the beginning to the end of a season, but significant changes did occur between starting and relief pitchers.

Clinical Relevance:

Adaptations to the daily routines of starter and reliever pitchers may be warranted on the basis of these findings.

First-rib stress fracture in a high-school lacrosse player: a case report and short clinical review

A 14-year-old right-hand dominant female lacrosse player presented with a complaint of right shoulder and upper posterior thorax pain of 8 days' duration. She had been playing lacrosse at the attack wing and midfielder positions and experienced insidious pain after a game. She had no history of trauma to that shoulder during that game and had not experienced an injury in the past. Six days after the pain developed, she woke up one night with a sudden increase in the pain, which brought her to tears and caused slight difficulty with breathing. The pain was located anteriorly just lateral to the right sternoclavicular joint and posteriorly in the paraspinal muscles in the upper thoracic region. Physical examination suggested a first-rib stress fracture, which was subsequently confirmed by chest and shoulder radiographs.

Abscess after a laparoscopic appendectomy presenting as low back pain in a professional athlete

A professional baseball player presented to the orthopaedic clinic for a preseason assessment because of continued lumbar spine and flank pain. He had a laparoscopic appendectomy for a perforated appendix 8 months before his presentation. He was able to finish the previous season with only mild limitation. He presented with back pain that limited his activity. His examination was nonlocalizing, but subsequent computed tomography revealed a hepatic abscess. The abscess was drained; he was treated with intravenous antibiotics; and his symptoms resolved.

Intraarticular abnormalities in overhead athletes are variable

BACKGROUND

The cause of shoulder pain and dysfunction in the overhead athlete can be variable. Several studies illustrate the wide variety of lesions seen at the time of arthroscopy in overhead athletes who require surgery but it is unclear whether these differ by sport.

QUESTIONS/PURPOSES

We examined overhead athletes with shoulder dysfunction to determine (1) the range of arthroscopically visualized shoulder abnormalities with specific attention to the posterosuperior glenohumeral joint and the rotator cuff; and (2) the relationship of sport type to these abnormalities.

METHODS

We reviewed our institution's database for professional and collegiate athletes in overhead sports who, from 1996 through 2010, had diagnostic shoulder arthroscopy for insidious, nontraumatic, persistent pain and inability to participate in their sport. A descriptive analysis of the arthroscopic findings from 51 consecutive patients (33 males, 18 females; mean age, 25 years; range, 15-59 years) was done. We analyzed the arthroscopic findings with respect to sport using analysis of variance and Fisher's exact test.

RESULTS

There was a wide range of superior labrum, posterosuperior glenoid, and rotator cuff abnormalities. Overall, the most frequent abnormalities were posterosuperior glenohumeral joint changes. Swimmers had fewer intraarticular abnormalities than baseball players.

CONCLUSIONS

We found a wide spectrum of intraarticular abnormalities in the shoulder of overhead athletes with shoulder pain requiring surgery. Additional study is needed to determine whether these abnormalities or combinations relate to specific athletic movements.

LEVEL OF EVIDENCE

Level IV, retrospective case series. See Guidelines for Authors for a complete description of levels of evidence.

Fly Fishing-related lesser tuberosity avulsion in an adolescent

Stress lesions of the shoulder in athletic and active adolescents are most commonly associated with overhead sports. One of the most uncommon stress lesions of the shoulder in adolescents is an avulsion of the lesser tuberosity of the proximal humerus. To our knowledge, only 2 other cases of lesser tuberosity avulsions from repetitive motion have been reported, both of which were secondary to baseball pitching.This article describes a case of an isolated partial avulsion of the lesser tuberosity of the humerus in an adolescent as a result of repetitive stress from fly fishing. The patient had no symptoms in his shoulder until after casting for approximately 10 hours a day for 3 days. He presented with anterior shoulder pain that worsened with abduction and external rotation. On examination, he had tenderness over the lesser tuberosity and pain with subscapularis muscle testing, such as the lift-off test. He had a negative apprehension sign but no signs of a superior labrum tear. Conventional radiography with an axillary view confirmed the diagnosis. He recovered with rest and gradual return to activities. Two years after injury, the patient had no limitations functionally, and his shoulder examination was normal.This case highlights the importance of being aware that (1) this lesion can occur in activities other than baseball, (2) characteristic physical findings exist with this lesion, (3) obtaining an axillary radiograph can confirm diagnosis, and (4) these avulsions can be treated successfully with nonoperative interventions.

Transtendon arthroscopic repair of high grade partial-thickness articular surface tears of the rotator cuff with biceps tendon augmentation: technical note and preliminary results

INTRODUCTION

Partial articular surface of the rotator cuff tendon tears has been recognized as a source of treatable shoulder pain and a precursory pathology for full-thickness tendon tears. Arthroscopic rotator cuff repair is a possible surgical method of treatment. Recent data have shown that the treating partial-thickness rotator cuff repairs with transtendon technique shows good clinical outcome. The use of this technique enables the reconstitution of the tendon with complete reconstruction of its footprint without damaging its intact bursal part. In cases of high grade partial articular-sided degenerative rotator cuff tears (involving >50% of the tendon) in older patients, there is a possibility of poor healing or re-tear of the rotator cuff repair, which may be associated with poor tendon quality and substantial thinning of the rotator cuff, subsequently revision surgery in these patients will be demanding.

METHODS

To mitigate these problems, we describe here a new arthroscopic transtendon repair technique with tenotomized long head biceps tendon augmentation for high grade partial articular rotator cuff tear with the goal of providing increase tendon healing, as well as to minimize the probability of failure of the construct and to improve the clinical outcomes.

RESULTS

The clinical results of the first 39 consecutive patients are reported showing significant decrease in pain and improved shoulder scores, as well as the post-operative range of motion and with no cases of re-tear of the rotator cuff tendon.

Case report: bilateral proximal epiphyseal clavicular stress-related lesions in a male gymnast

BACKGROUND

Stress lesions of the upper extremity are relatively uncommon, and physeal stress lesions of the clavicle are rare. We present a case of bilateral physeal stress-related lesions of the proximal clavicular growth plate near the sternoclavicular joint in an adolescent male gymnast.

CASE DESCRIPTION

A 13-year-old gymnast presented with a 3-week history of insidious onset of pain in the proximal clavicular area of his left shoulder. He had no pain at rest or at night. He recently had added a new maneuver to his routine. His radiographs were normal, but further study with CT scanning confirmed a stress lesion of his proximal clavicular physis. The lesion healed with time, and he returned to gymnastics with no symptoms. Approximately 5 months after the initial symptoms on the left side, he felt a pop and immediate pain in his right sternoclavicular joint area while doing a routine. Imaging revealed a chronic stress lesion of the proximal physis similar to that of the other side. The patient achieved healing with rest and returned to gymnastics with no limitations.

LITERATURE REVIEW

Physeal stress-related lesions of the proximal clavicular physis have not been reported in the literature.

PURPOSE AND CLINICAL RELEVANCE

Medial clavicle pain in adolescent gymnasts may be secondary to stress-related lesions of the proximal clavicular growth plate. Such lesions are rare.

Complications of the reverse prosthesis: prevention and treatment

Reverse total shoulder arthroplasty was developed in the late 1980s for elderly patients with rotator cuff arthropathy. Several biomechanical advantages of the reverse shoulder arthroplasty result in improved deltoid function, which improves shoulder motion and function compared to other types of shoulder arthroplasty. The main indication for the reverse prosthesis is painful rotator cuff tear arthropathy. The indications for reverse shoulder arthroplasty have continued to expand since it was first performed in the United States in 2004. Although the results of reverse total shoulder arthroplasty have been generally favorable, the complication rate is higher than that of conventional total shoulder arthroplasty. Complications include those common to other shoulder procedures (infection, instability, and nerve injury) and those unique to reverse total shoulder arthroplasty (scapular notching, glenoid baseplate failure, component disassociation, and scapular stress fractures). It is helpful for orthopaedic surgeons to understand ways to avoid these complications and methods with which to treat them.

Painful os acromiale presenting as septic shoulder

The unfused acromial apophysis of an os acromiale typically is an undetected orthopedic anomaly with minimal symptoms. In some instances, however, pain and disability can result from motion between the unfused bone fragments. Trauma to the acromion can similarly displace the unfused os acromiale or can result in chronic symptoms of pain and swelling. In this article, we report the case of a young man who had a fractured os acromiale secondary to trauma and presented with the signs and symptoms of a septic glenohumeral joint.

Biomechanical evaluation of open suture anchor fixation versus interference screw for biceps tenodesis

Biceps tenodesis provides reliable pain relief for patients with biceps tendon abnormality. Previous cadaver studies have shown that, for biceps tenodesis, an interference screw provides biomechanical strength to failure superior to that of suture anchors. This finding has led some providers to conclude that screw fixation for biceps tenodesis is superior to suture anchor fixation. The purpose of the current study was to test the hypothesis that the strength of a 2-suture-anchor technique with closing of the transverse ligament is equal to that of interference screw fixation for biceps tenodesis.In 6 paired, fresh-frozen cadaveric shoulder specimens, we excised the soft tissue except for the biceps tendon and the transverse ligament. We used 2 different methods for biceps tenodesis: (1) suture anchor repair with closing of the transverse ligament over the repair, and (2) interference screw fixation of the biceps tendon in the bicipital groove. Each specimen was preloaded with 5 N and then stretched to failure at 5 mm/sec on a materials testing machine. The load-to-failure forces of each method of fixation were recorded and compared. Mean loads to failure for the suture anchor and interference screw repairs were 263.2 N (95% confidence interval [CI], 221.7-304.6) and 159.4 N (95% CI, 118.4-200.5), respectively. Biceps tenodesis using suture anchors and closure of the transverse ligament provided superior load to failure than did interference screw fixation. This study shows that mini-open techniques using 2 anchors is a biomechanically comparable method to interference fixation for biceps tendon tenodesis.